When Trauma Includes a TBI John D. Corrigan, PhD Tim Schilling, MSW Participants will Learning Objectives 1. understand why traumatic brain injury frequently causes problems in self-regulation. 2. be able to describe why TBI and trauma co-occur. 3. be able to identify at least three elements of an integrated care approach to treatment planning for people with co-occurring trauma and TBI. 1
What is a traumatic brain injury or TBI? TBI occurs when an external force causes an alteration in consciousness Effects can be temporary or permanent Range from mild to severe A concussion is a mild TBI There are additional effects from repeat injury 2
Cumulative Effects of Concussion In 15,300 high school and college football player/ seasons, those with a history of concussion were almost 6 times more likely to have another, almost twice as likely it would include loss of consciousness (Zemper, 2003). In 2,900 college football players, those with 3 concussions were 3 times more likely to have another; history of concussion was associated with slower recovery (Guskiewicz, et al 2003). Cumulative Effects of Concussion (Guskiewicz et al, 2003) Adjusted Rate Ratio % Prolonged Recovery 3 3.0 30% 30% 2.5 2 1 1.0 1.4 0 1 2 3+ 20% 10% 20% 15% 7% 0 0% 3
TBI due to Blasts the signature injury of combat in Iraq and Afghanistan Can blast forces alone cause mild TBI? If so, is it the same pathology as TBI caused by mechanical forces? What about multiple blasts? Unanswered questions about the cumulative effects of impacts to the head Number, spacing or strength? Type of injury (high velocity, blast)? Present even without symptoms (the subconcussive injury)? Uses up reserves, triggers a pathological process or both? Are some people at more risk than others (genetic, epigenetic)? 4
Groups Who May Have Multiple Mild TBI s Military personnel, particularly those with combat deployment in OEF/OIF Athletes, particularly boxers, football players & hockey players Victims of intimate partner violence and childhood physical abuse People who misuse and abuse substances People who are homeless Province of Ontario (Ilie et al. 2015a,b,c) Lifetime history of TBI with 5 minutes loss of consciousness or hospital stay More likely to smoke cigarettes (AOR=2.15) use cannabis (AOR=2.80) and use nonprescription opioids (AOR=2.90) More likely to be experiencing psychological distress (AOR=1.97) More likely to screen + for ADHD (AOR=2.49) or have been diagnosed with ADHD (AOR=2.64) More likely to have had a motor vehicle crash with injuries (AOR=1.79) More likely to have engaged in serious driver aggression during past 12 months (AOR=4.39) *Adjusted for sex, age and education 5
State of Ohio (Corrigan et al., in preparation) Lifetime history of TBI with at least 1 TBI with >5 minutes loss of consciousness More likely to engage in heavy drinking (AOR=1.9) More likely to smoke cigarettes (AOR=2.6) More days of tension/anxiety (AOR=3.3) More days of depressed mood/sadness (AOR=3.5) More likely depression in one s lifetime (AOR=2.7) More days of poor mental health (AOR=2.2) More days of poor physical health (AOR=1.8) More days of pain (AOR=2.7) More likely diagnosed with a chronic disease (AOR=2.7) More likely to have a disability (AOR=3.4) *Adjusted for sex, age, race of medical attention received Correlates of Lifetime TBI among Adolescents (Ilie et al., 2014) Behaviors reported by 7th-12 th graders in Ontario Canada (N=4,685) No TBI* Lifetime TBI* Odds** (95% CI) Elevated psychological distress 32.4% 39.2% 1.52 (1.19, 1.94) Suicidal ideation 9.2% 15.2% 1.93 (1.42, 2.63) Suicide attempt 2.0% 5.9% 3.39 (2.15, 5.35) Sought counseling through a crisis help line 1.8% 3.5% 2.10 (1.18, 3.75) Prescription for anxiety &/or depression 2.7% 5.9% 2.45 (1.08, 5.56) Took a car without owners permission 4.4% 12.7% 3.47 (1.96 6.15) Beat up or hurt someone on purpose 7.1% 14.7% 2.21 (1.57 3.12) Sold marijuana or hashish 4.1% 9.6% 2.58 (1.45 4.61) * TBI if 5 minutes loss of consciousness or overnight hospital stay ** Odds ratio adjusted for grade, sex and sampling strata 6
Correlates of Lifetime TBI among Adolescents (Ilie et al., JHTR 2014) Behaviors reported by 9th-12 th graders in Ontario Canada (N=6,288) No TBI* Lifetime TBI* Odds** (95% CI) Tobacco use daily 3.9% 9.2% 2.48 (1.45, 4.25) Alcohol use 63.7% 77.0% 2.01 (1.52, 2.67) Alcohol binging 26.4% 39.3% 1.87 (1.49, 2.35) Cannabis use 25.2% 39.5% 2.00 (1.60, 2.50) LSD use 1.1% 3.0% 2.56 (1.45, 4.52) Cocaine 1.9% 4.6% 2.49 (1.75 3.54) Ecstasy 3.3% 8.7% 2.82 (1.73 4.58) Methamphetamine/crystal meth 0.8% 2.9% 3.77 (2.21 6.41) * TBI if 5 minutes loss of consciousness or overnight hospital stay ** Odds ratio adjusted for grade and sex Three Sources of the Behavioral Problems Caused by TBI Pathophysiology structural damage from TBI disinhibits behavior Neurobehavioral TBI changes how we view rewards and consequences Developmental early life TBI predisposes a person to behavioral problems 7
The Fingerprint of TBI Pathophysiology Frontal areas of the brain, including the frontal lobes, are the most likely to be injured as a result of TBI, regardless the point of impact to the head Pathophysiology The brain is set into motion along multiple axial planes 8
Interior Skull Surface Pathophysiology Bony ridges Injury from contact with skull Pathophysiology Areas of contusion in (Courville, 1950) Loss of gray matter one year post-injury (Bigler, 2007) 9
Pathophysiology Simplified Brain Behavior Relationships Frontal Lobes Initiation Problem solving Judgment Inhibition of impulse Planning/anticipation Self-monitoring Motor planning Personality/emotions Awareness of self Organization Concentration Mental flexibility Speaking Frontal Lobe Temporal Lobe Parietal Lobe Occipital Lobe Cerebellum 10
Developmental Contributions Early childhood TBI, even if mild, may pre-dispose to later behavioral problems. Natural History of TBI to Age 25 (McKinlay et al., 2008) 1,265 children born in 1977 in Christchurch, New Zealand and followed to age 25 Annual assessments from 4 months to age 16, then at 18, 21 and 25 Verified through medical records all TBI s diagnosed by a professional (MD office, ED, hospitalized) 79.3% successfully followed through age 25 Developmental 11
Early Injury as Predictor of Later Problems Developmental Compared to no TBI and outpatient only, by early adolescence (10-13 y.o.) those hospitalized with a mild TBI before age 6 were: More hyperactive and inattentive as rated by parent and teacher More likely dx d with ADHD, conduct disorder or oppositional defiant behavior More likely to have substance abuse problems More likely to demonstrate mood disorders Developmental Early Injury as Predictor of Later Problems (continued) By late adolescence and early adulthood (16-25 years old): Those hospitalized with 1st TBI before age 6, 3 times more likely to have a diagnosis of either alcohol or drug dependence by age 25 Those hospitalized with 1st TBI 16-21, 3 times more likely to be diagnosed with drug dependence TBI highly associated with likelihood of arrest 12
Association between TBI and Arrests Developmental Mean Number of Arrests 3.0 2.5 2.0 1.5 1.0 5.46** 1.63* 1.65* 3.52** Relative Risk Ratios * p<0.05 ** p<0.01 0.5 0 1st TBI 0-5 1st TBI 6-15 Reference Outpatient Inpatient Swedish Population Registry 1.1 million Swedish citizens born between 1973 and 1985 and followed to 2013 9.1% had a medically treated TBI by age 25 Compared outcomes to general population, siblings without TBI and persons with orthopedic injuries Looked at likelihood of the following outcomes: psychiatric treatment disability from work psychiatric hospitalization receiving welfare benefits premature mortality low educational attainment 13
Adjusted Odds of Negative Consequences Compared to Uninjured Siblings Any TBI Mild TBI Mod/Sev TBI Recurrent TBI Disability pension 1.49 1.36 2.06 2.22 Psychiatric visit 1.31 1.31 1.34 1.24 Psychiatric hospitalization 1.57 1.51 1.75 1.53 Premature mortality 1.40 1.26 1.92 1.59 Low education 1.28 1.25 1.37 1.28 Welfare recipiency 1.19 1.18 1.21 1.13 Adj. Odds of Negative Consequences x Age at 1st Injury 0-4 5-9 10-14 15-19 20-24 Disability pension 1.39 1.37 1.58 1.85 1.97 Psychiatric visit 1.18 1.19 1.40 1.60 1.78 Psychiatric hospitalization 1.24 1.33 1.68 2.04 2.47 Premature mortality 1.28 1.40 1.45 1.76 2.25 Low education 1.32 1.24 1.43 1.73 1.67 Welfare recipiency 1.33 1.35 1.40 1.56 1.70 14
Adj. Odds of Negative Consequences x Age at 1st Injury Compared to Uninjured Siblings 0-4 5-9 10-14 15-19 20-24 Disability pension 1.29 1.28 1.49 1.73 Psychiatric visit 1.11 1.28 1.24 1.53 Psychiatric hospitalization 1.42 1.62 1.92 Premature mortality 1.24 1.59 Low education 1.10 1.22 1.41 1.34 Welfare recipiency 1.19 1.20 1.24 Brief Re-cap Regardless where the impact is on the head, the frontal lobes are most likely injured Frontal lobes are critical to behavioral control and, in turn, success in society Greater impulsivity and disinhibition may result from changes in how rewards and consequences are processed Early developmental injuries have consequences even when mild 15
Whether working in mental health, substance abuse, criminal justice or other systems, it is worthwhile to know whether the person you are working with has had a TBI. Informative Websites: www.ohiovalley.org/informationeducation www.brainline.org Brain Injury Association of Ohio: www.biaoh.org (800) 444-6443 (toll-free) Free training on how to screen for TBI: www.ohiovalley.org/tbi-id-method 16